- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $8,042.03
| Facility | | $3,496.00 | $4,964.00 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.89 / $1,065.89 / $2,642.94
| Professional | | $640.89 | $1,065.89 | $2,642.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.58 / $1,745.31 / $12,342.67
| Facility | | $1,060.58 | $1,745.31 | $12,342.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.75 / $1,745.31 / $8,688.37
| Facility | | $1,259.75 | $1,745.31 | $8,688.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |